Atlanta Consumer Insight Center. Pet Lovers Needed! Earn $75
Thank you for your interest in our upcoming study.  The study is going to be held in downtown Atlanta and will be about an hour and a half long.  Please fill out the following questionnaire as accurately as possible.  Respond with clearly marked answers to each question.  Questions marked with a red star are required.

Please note that all information gathered throughout this process is kept strictly confidential.  For more information about our company, you may visit www.neurofocus.com.

*There are different qualifications for each study and each study has a different survey.  Sometimes our surveys look similar or even identical but we are always looking for different qualifications.  
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First Name: *
As shown on ID
Last Name: *
As shown on ID
Email Address *
Please be sure to enter your email address correctly
Exact Birthdate - As Shown on ID *
Please write as Month/Day/Year
Age *
Do you have a valid photo ID (so we can verify your name and age)? *
Phone number: *
Please include dashes (e.g., XXX-XXX-XXXX)
City of residence: *
Zip code: *
Education: *
Please specify your highest level of education (e.g., High school graduate, Some college, Associate's degree, Bachelor's degree, Masters degree, JD, PhD, MD, etc.).
Annual household income: *
Please specify your average annual income, including contributions from all members of the household.
How many children under 18 years of age do you have? *
Ethnicity: *
Gender: *
Marital status: *
Women only: Are you currently pregnant or nursing? *
Which is your dominant hand? *
Are you able to sit for up to 1.5 hours without any discomfort due to chronic pain? *
Are you currently smoking? *
Which of the following, if any, have you taken or used in the PAST 6 MONTHS? *
Required
Are you currently sick with a cold or allergy? *
Describe your vision/eyesight: *
Are you currently diagnosed with any medical condition? *
If yes, please specify.
Are you currently taking any medications? *
If yes, please specify.
Have you been diagnosed with any type of neurological illness? *
Have you been diagnosed with epilepsy? *
Are you being treated for any mood related, memory related, or sleep related condition presently or have you been within the past 3 months? *
Do you have any type of heart condition? *
If yes, please specify.
Have you experienced any head trauma, brain trauma, or brain surgery? *
If yes, please specify.
Do you have a history of, or have you ever been treated for, any of the following? *
Please check all that apply
Required
Do you have any of the following? *
Please check all that apply.
Required
Have you recently dyed your hair (within the last week)? *
Have you participated in a focus group or usability study for which you were compensated in the past 6 months? *
Do you or does anyone in your household work for any of the following? *
Please check all that apply.
Required
Are you comfortable undergoing an EEG procedure? *
During the study you will be watching a presentation on a TV monitor while we measure your responses using an EEG cap. The EEG cap is like a modified swim cap. It contains tiny holes where we apply a small amount of leave-in conditioner gel and snap on some sensors. The gel may come in contact with your scalp but the sensors do not. The whole process is very passive; there is no pain associated with the procedure.
Are you willing to sign a consent form when you come in for the study? *
How did you hear about us? *
If you answered "Friend" to the question above please specify your friends name.
Do you wish to "opt in" to receive future emails regarding ACIC paid studies? *
Do you own a dog? *
Do you own a bird? *
Do you own a fish? *
Do you own a cat? *
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